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Whilst trying to think of non-chemical/hormonal causes of low self-esteem when reading Is low self-esteem, a brain chemical imbalance problem, rather than a personality defect, and can't be fixed by any amount of counselling/self-help?, I have been considering Body Dysmorphia Disorder (BDD).

Whilst it is a mental disorder in its own right, I have been thinking that BDD can cause depression due to the constant upset caused by the feelings concerning the body, but not the other way round; yet the UK mental health charity, Mind, states.

No one knows exactly what causes BDD. However, recent research suggests that there are a number of different risk factors that could mean you are more likely to experience BDD, such as:

  • abuse or bullying
  • low self-esteem
  • fear of being alone or isolated
  • perfectionism or competing with others
  • genetics
  • depression or anxiety

I am asking here specifically about depression because for the other reasons in MINDs list such as perfectionism or bullying, anxiety could cause BDD in my thinking.

With risk not necessarily meaning cause, in order for the risk to be quantified, there needs to be indication from studies and past clients that depression led to BDD rather than the other way round, and yet I am not convinced of this.

What studies are available which indicate that depression can cause BDD rather than the other way round?

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    $\begingroup$ It's hard to establish cause and effect when it comes to co-morbidities. Even though you say BDD "is a mental disorder in its own right," all that means is that we can cluster the symptoms. The Wikipedia article on BDD says "BDD shares features with obsessive-compulsive disorder,[6] but involves more depression and social avoidance.[1] BDD often associates with social anxiety disorder.[7]" BDD and depression could be both largely influenced by overlapping genetic or personality factors, e.g. neuroticism. $\endgroup$ – Fizz Jul 20 '18 at 15:58
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TLDR version: it appears depression-as-a-risk-factor-for-BDD hasn't actually been studied, so the quoted UK NGO claims might stem from a blurring of risk factors and comorbidity.


Let's start by recalling what risk factor actually means (it does not mean cause):

Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes.

So support the quoted passage in your question, one would only have to show that depression (from whatever cause) can happen before BDD in some individuals. If someone is predisposed to "go off the deep end" because of their body, they could possibly do that for any other perceived insufficiency in themselves (like thinking they're not being smart enough). The criteria to BDD are extremely specific, only a preoccupation with physical appearance counts; if someone ruminates or obsesses or over their (perceived) lack of intelligence, that doesn't qualify for BDD. With this in mind, depression being a risk factor for BDD doesn't so improbable.

Alas, I came up empty for an actual longitudinal study where depression got worse before BDD... but I did find one close enough:

We found several significant longitudinal associations between BDD and the comorbid disorders we examined. The association was strongest for depression. Time-varying associations showed that improvement in BDD and major depression were closely linked in time, with significant associations in both directions: improvement in major depression predicted BDD remission, and improvement in BDD predicted major depression remission. This finding suggests that the same etiologic processes contribute to both BDD and major depression in some subjects.

The reason they could only talk of improvements (and not deterioration) is that this study had a treatment-based time frame. So there's wasn't much in the way of naturalistic observation sans treatment. That would probably require a much longer time scale... and I'm not convinced someone could get funding for that... especially since it raises ethics questions like observing depression getting worse in some patients but not doing anything about it, just so BDD aggravation could be observed.

On the other hand, the common sense logic (that you had) that depression might usually come after BDD, turns out to be supported by this study (well, again based on remission):

in our sample depression may be largely secondary to BDD for many subjects, as a substantial proportion remitted from major depression following BDD remission. Conversely, after remission of depression, BDD tended to improve but less markedly. Our findings additionally suggest that BDD is not simply a symptom of depression. If it were, BDD would be expected to remit around the time of depression remission and during subsequent months.

Frankly, I suspect that the NGO page in question might have simply confused (or amalgamated) risk factors with comorbidity. I'm saying this because a 2015 research paper notes that very little is know about risk factors for BDD. According to that paper, the only things which have been investigated as risk factors for BDD being:

  • "perceived teasing about general appearance"
  • "emotional, physical, or sexual abuse or neglect resulting in poor attachment and body shame"
  • "a genetic predisposition for a need for symmetry or order"
  • "being excessively self-conscious about appearance changes during adolescence"

So, my conclusion from all this: it sounds somewhat plausible that depression is a risk factor for BDD (based on the common etiology [in some people] hypothesis), although it doesn't seem to have been formally/directly investigated, and the reverse occurence of events (BDD first, then depression) sounds a bit more common/likely.

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  • $\begingroup$ Thanks for your answer but I am not totally convinced. With risk not meaning cause, whilst I see your point, in order for the risk to be quantified, there needs to be indication from studies and past clients that depression led to BDD rather than the other way round, and yet I am not convinced of this. $\endgroup$ – Chris Rogers Jul 22 '18 at 8:18
  • $\begingroup$ ”If someone is predisposed to "go off the deep end" because of their body, they could possibly do that for any other perceived insufficiency in themselves (like thinking they're not being smart enough). ” - I would argue that with this scenario, the client could possibly be already suffering from a case of BDD to start with which causes upset (not depression yet). Due to the fact that nothing is changing for the better the depression later sets in. $\endgroup$ – Chris Rogers Jul 22 '18 at 8:27
  • $\begingroup$ @ChrisRogers: I've added a summary. I wasn't trying to convince you. $\endgroup$ – Fizz Jul 22 '18 at 8:33
  • $\begingroup$ @ChrisRogers: Also BDD doesn't apply to "I think I'm stupid" (intelligence preoccupation); it has specific criteria relating to body (but not mind) image.Such are the twists of modern psychiatric classification. bdd.iocdf.org/professionals/diagnosis $\endgroup$ – Fizz Jul 22 '18 at 8:41
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TL;DR:

In one study I found, major depression preceded onset of BDD in 22% of cases (Gunstad & Phillips, 2003).

More Complete Answer

Reading Phillips & Stout (2006) linked in the answer by @Fizz, they state that (emphasis added)

Our findings additionally suggest that BDD is not simply a symptom of depression. If it were, BDD would be expected to remit around the time of depression remission and during subsequent months.

Also highlighted in Phillips & Stout (2006) was the fact that a double-blind cross-over study in BDD found that the SRI clomipramine reduced depressive symptoms more than the non-SRI antidepressant desipramine; this finding suggests that depression was secondary to BDD (Hollander et al., 1999).

In Phillips & Stout's study:

[D]uring the 3 months after remission of major depression, BDD persisted for most subjects, with fewer than 30% of subjects attaining full remission from BDD.

To add to this, Gunstad & Phillips (2003) had this to say:

[O]ur finding that major depression usually began after BDD may simply reflect the fact that major depressive disorder typically begins in the mid-20s, whereas BDD usually begins in the early to middle teenage years. An alternative explanation is that major depression may reflect depressive symptoms and demoralization as a secondary complication of BDD. Although it cannot be determined whether one disorder causes another, our clinical impression is that the major depression that so frequently co-occurs with BDD is often due to BDD; however, this does not always appear to be the case. Indeed, in this study major depression preceded onset of BDD in 22% of cases. It is also worth noting that onset of social phobia usually preceded onset of BDD, as would be expected based on social phobia’s usual age of onset. This suggests that in this study, “primary” social phobia was differentiated from the marked social anxiety typically caused by BDD, which would be expected to begin at the time of, or after, onset of BDD. It is sometimes difficult clinically to differentiate primary social phobia from social anxiety secondary to BDD.

References

Gunstad, J., & Phillips, K. A. (2003). Axis I Comorbidity in Body Dysmorphic Disorder. Comprehensive Psychiatry, 44(4), 270–276.
DOI: 10.1016/S0010-440X(03)00088-9 PCMID: PMC1613797
Free PDF: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613797/pdf/nihms12699.pdf

Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., & Simeon, D. (1999). Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Archives of General Psychiatry, 56(11), 1033-1039.
DOI: 10.1001/archpsyc.56.11.1033 PMID: 10565503

Phillips, K. A., & Stout, R. L. (2006). Associations in the Longitudinal Course of Body Dysmorphic Disorder with Major Depression, Obsessive Compulsive Disorder, and Social Phobia. Journal of Psychiatric Research, 40(4), 360–369.
DOI: 10.1016/j.jpsychires.2005.10.001 PMCID: PMC2786172
Free PDF: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786172/pdf/nihms92762.pdf

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